Tinnitus
last authored: August 2009, David LaPierre
last reviewed:
Introduction
Tinnitus is a ringing, rushing, or roaring noise that can be real or imagined. Perhaps 10% of people experience tinnitus, although over 90% of people hear something in a soundproofed room (Heller and Bergman, 1953). Tinnitus following nerve damage can be compared to phantom limb pain.
The Case of Mary Tweed
Mary Tweed is a 53 year-old presents to her family physician with a 3 month history of worsening buzzing in her left ear.
What is the differential diagnosis, and what investigations, if any, should the family physician perform?
Differential Diagnosis
Tinnitus is most common in people exposed to long-term, loud noise.
Subjective tinnitus, or noise only the patient can hear, can be caused by many conditions and diseases. Some of these include:
- noise-induced hearing loss
- prebycusis
- Meniere's disease
- otosclerosis
- middle ear effusion
- trauma
- ototoxic drugs (aminoglycosides, loop diuretics)
- labyrinthitis
- acoustic neuroma
- wax buildup
Objective tinnitus which can also be heard by an observer, can be caused by
- temperomandibular joint or palatal musculature
- vascular: normal carotid artery, glomus jugulare, AV malformations, carotid body tumours
History and Physical Exam
- history
- physical exam
History
Tinnitus is extremely, usually benign, and history and physical exam are often sufficient to make a diagnosis.
- clicking or popping noises are usually caused by the middle ear
- high-pitched hissing or rushing usually caused by inner ear or brain
- pulsatile: blood flow, musculoskeletal
Physical Exam
Investigations
Tinnitus does not usually require further investigation.
However, red flags include unilateral symptoms, especially if accompanied by hearing loss.
Management
The psychological impact of tinnitus can be profound, particularly if patients are worried about malignancy. Reassurance is paramount and can often lessen the subjective experience of tinnitus.
Hearing loss should be identified and treated.
Noise machines can cover up tinnitus and can help a proportion of patients.
Psychotherapy and group meetings can be helpful for the group of patients overwhelmed with their condition.
Pathophysiology
Resources and References
Heller MF, Bergman M. 1953. Tinnitus aurium in normally hearing persons. Ann Otol Rhinol Laryngol. 62(1):73-83.
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